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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MASTERFILE RECORD INFORMATION FORM ❑ New EH Program at Existing Facility ❑New EH Program and New Facili Facility ID Program Record ID i 6 25 Facility Address -e TSAn} znn A/� C4 �l�} Slplo (Please check the appropriate description and specify size, number of units and pertinent information.) FOOD PROGRAM(1600) ❑ Restaurant: Seating Capacity Square Footage Food Handlers Course required: YES ❑ No ❑ ❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines Number of Units ❑jtetail Market----Square footage ❑ w/Meat Market only ❑ Multiple Departments❑ Prepackaged Goods Only Mobile Food Vehicle--Make Vehicle Type Color Registration# License# Sticker# ❑ Mobile Food Prep Unit--Make Vehicle Type Color Registration# License# Sticker# ❑ Temporary Food Facility--Dates of operation from to ❑ Ice Plant❑ Produce Stand ❑ Special Event---Dates of operation from to ❑ CFO CIAO B DAIRY PROGRAM(2000) ❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser-Number of Containers in Multi-Head Unit CUPA ❑ Hazardous Materials Business Plan (1900) Number of chemicals: ❑ CaIARP Program ❑ Program 1 Facility ❑ Program 2 Facility ❑ Program 3 Facility ❑ Hazardous Waste Generator(2200)---------->-Tons Generated Per Year ❑ Tiered Permitting Facility-------> ❑ CA(2232) ❑ CE(2233, 2234, 2235,2237) ❑ PBR (2231) ❑ PBR HHW(2236) ❑ Aboveground Storage Tank Facility(AST) (2800) Number of ASTs ❑ Underground Storage Tank Program (UST) (2300) Use UST A and B forms ❑ Other CUPA Program HOUSING PROGRAM(2400) ❑ Hotel/Motel------Number of Units ❑ Jail or Exempt Institution----Number of Units Employee Housing (2700) Use Employee Housina/Labor Camp Application Form SITE MITIGATION(2900) UNDERGROUND INJECTION CONTROL(3000) ❑ Environmental Assessment ❑ UST-CAP Site ❑ Local HW Cleanup Site ❑ NPL/SEP Cleanup Site ❑ UIC Site ❑ Abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site RECREATIONAL HEALTH PROGRAM(3600) Number of Pools/Spas at Facility ❑ Pool ❑ Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area VECTOR CONTROL PROGRAM(4000) ❑ Poultry Farm-------Maximum number of birds ❑ Kennel TATTOO,BODY PIERCING,PERMANENT COSMETIC PROGRAM (4100) ❑ Body Art Practitioner Reg (4110) ❑ Mechanical DSPS Notification (4115) ❑ Body Art Facility-Single Use(4120) ❑ Body Art Facility-Sterilization (4121) ❑ Body Art Temp Event Co-ord (4130) ❑ Body Art-Temp Event Mobile Facility(4131) LIQUID WASTE PROGRAM(4200) ❑ Pumper Vehicle Registration# License# Capacity Vehicle# ❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets----Number of Units SOLID WASTE PROGRAM (4400) pp 1:1 Landfill 11 Transfer Station IJAg/Cannery Waste Site ❑ Sluc!! ❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIAkle' El Refuse Vehicles(#of units) ❑ Dumpsters> 20 cu yd (#of Units) ❑ Firnm/Ran p Site MEDICAL WASTE PROGRAM (4500) RV v 0 29/�y� 11 Primary Care 11 Acute Care 13 Skilled Nursing ❑ Large Generator 11 Small Genev$% 11Limitefyauler ❑ Transfer Station 11 Veterinary Clinic 11 Common Storage Facility ❑ 2- 10 ❑ 11 -aovvOA PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form HATH DEP ENTq( EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM �TMENT CONTACT PERSON MII A gc6I 0 u Day Ph 02S- -g I Night Ph 025 —lQ(.a1-$l t oD PROGRAM ELEMENTr_y I(D J FEE l� 231 — ❑ Surch rge FEE 1:1 Other FEE INSPECTOR# _ SO I PERMIT VALID 12o t0 ZD�L 1:1Food Handler 77Z❑❑ Check# AMO NT PAID Date 11 12-12-b INVOICE# 3,447-72- 11 Cash CofCf REVIEWED BY AA ACCOUNTING OFFICE 1 Date 48-02-034 MASTERFILE RECORb INFORMATION PINK 1/23/13